Is your in-network insurance going to cost you more for physical therapy than going out of network?


When you decide to go to a physical therapist, you have taken the first step toward feeling better. Admitting you need help with your body from a professional is a big decision — but then what?

You ask Google who the best therapist is. You turn to friends and family for suggestions. Maybe you even call a few places to see if your insurance covers treatment there. Sooner or later you find the great divide in our healthcare system. Do I stay in network or do I go out of network?

When most people hear “out of network” there is a cringe response followed by dollar signs fading into the distance. This gut reaction exists because information on how insurance companies can dictate your treatment is largely swept under the carpet, leaving the consumer undereducated and under-served.

Let’s first look at what it means to be ”in-network” from a therapist’s point of view. To be in-network is to be in a contract with an insurance company, which means there are terms and conditions that allow the insurance company to dictate a large amount of how and what treatments are covered. This control is often exerted by limiting reimbursement for certain types of treatment, thereby forcing the therapist to increase the volume of patients per hour to keep the business profitable.

Yes, insurance companies make money by reimbursing as little as possible. But how can they legitimately pay less than the treatment actually costs the therapist?

In determining what services are reimbursable, insurance companies must decide if certain procedures were medically necessary and if a skilled therapist was required to perform them. So when an in-network therapist bills for $120, the insurance company can look at what happened during that treatment and decide that only half of it required a therapist present, or that some exercises were not relevant to the case, and can then deny part of the claim and reimburse the therapist only $60! This significantly cuts the incentive of the therapist to create a highly effective treatment for you since he knows there is little correlation between his effort and payoff, creating a cat and mouse game between insurance companies and providers.

Keep in mind that the insurance company will never know how you feel, or what part of the treatment truly helped you the most. They will look over medical notes written by a therapist to see what part of the claim they can deny or try to prove isn’t medically necessary — that’s their business model.

This forces the in-network therapist into a high-volume, low-attention business model (“Sorry– I have to write this medical note so we might get reimbursed”)  in which they see at least three patients per hour, many times more, just to keep the business profitable.

Now let’s look at this same scenario from your perspective. When you go to an in-network provider, you will not be the only one there, literally. Because he or she will need to be continuously treating several patients per hour, you can expect only 10 minutes of one-on-one time with a therapist who actually lays his hands on you. The other 30-40 minutes will be filled up with exercises that you can do on your own. You will be guided through these exercises by accessory staff like aides and athletic trainers who know considerably less about the body than a well-trained physical therapist. They will praise you for becoming independent in your exercise routine because they know this brings you pride and allows them to provide less supervision.

Remember, this is all happening because your insurance company doesn’t want to reimburse enough per treatment to allow therapists to spend more time with their patients.

So why isn’t every therapist out of network? Put simply, you need to be worth your dollar. Without the continuous referrals through insurance companies and physicians, out-of-network providers succeed through results and word of mouth. If you’re not happy, their business suffers. This gives the consumer much more power.

Now that you have some understanding of what’s going on in-network, let’s look at what going out-of-network really means.

Yes, you will pay more per visit. On average, the cost for out-of-network treatment in NYC is $200. But during that visit you will experience 40-60 minutes of one-on-one, hands-on time with a very skilled therapist. One session in this fashion can be equated to 6 or 7 visits  (and 6 or 7 co-pays) at an in-network facility that is primarily based on supervised exercise.

At Body Tuning & Physical Therapy, we provide faster than usual results because we are able to spend 40 to 60 minutes of time and energy on each patient. It’s simply a matter of quality over quantity. This extends beyond the therapist’s skill to include the facility itself.

There is usually minimal privacy at an in-network facility, and the over-stimulating music often played might be good for a glorified workout, but not great for healing. Out-of-network facilities usually have a more homelike feel to them with natural light and fresh air, factors that help the patient relax and focus on the changes that are being made to the body.

Maybe you are still doing math and thinking that you’ll never pay enough co-pays to justify going out of network. Don’t forget to add the value of your time and effort into the equation. A faster result equals less pain in less total treatments.

Let’s take Patient X, who has a frozen shoulder. With a skilled, out-of-network manual therapist this can be resolved in an average of 10-15 treatments. It is not uncommon, as some of our patients have expressed, for Patient X to seek care at an in-network sports medicine facility for over 30 treatments and make minimal progress!

Who would let this happen to themselves? The inexperienced consumer who isn’t familiar with the intricacies of our health care system. And the patient who hasn’t experienced good care before and is at the mercy of what some professionals tell her about needing to do lots of strenuous exercise and about pain being a good thing. What could patient X, or you, do with an extra 20 hours and 20 less strenuous therapy sessions?

The biggest barrier for consumers to get through when considering in versus out of network is the lack of information on how insurance companies are affecting in-network treatments. I’ve never met a bad therapist working in network, but I’ve also never met a therapist that wasn’t strapped for time, stressed, and handling four patients an hour. Is that who you want putting their hands on you for 10 minutes?

Make the decision and go out-of-network so you can experience what real physical therapy is supposed to be, not what it has become ever since the insurance lobby started undermining consumers.